Pensar Enfermagem / v.29 n.Sup / Jan-Dec 2025
DOI: 10.71861/pensarenf.v29iSup.412 / e00412
Qualitative Original Article
How to cite this article: Zidan J, Telles AC, dos Reis BS, Kiesse ATSN, Sá E, da Silva MM. Perception of
Healthcare Professionals on Palliative Care in Primary Healthcare: A Quasi
-
Experimental Study. Pensar Enf
[Internet]. 2025
Jan-Dec; 29(Sup): e00412. Available from:
https://doi.org/10.71861/pensarenf.v29iSup.412
Perception of health professionals regarding
palliative care in primary health care: a quasi-
experimental study
Abstract
Introduction
Primary health care is responsible for promoting health, preventing diseases, and managing
chronic conditions, including providing palliative care for patients and families, alleviating
suffering, and improving quality of life. However, this setting faces challenges related to
palliative care, such as the lack of provider education. Continuing education is a tool for
integrating generalist and specialized palliative care, enhancing the equity and quality of care
at this level of the health care network, including home-based care.
Objective
To assess health professionals’ perception of palliative care in primary health care before
and after a training course on the basic principles of this field.
Methods
This is an uncontrolled quasi-experimental study with a single group involving pre- and post-
intervention evaluation of an educational intervention, following adapted STROBE
guidelines. We conducted the interventions at the National Cancer Institute in July/August
2023, targeting health professionals from the municipality of Duque de Caxias, Rio de
Janeiro, Brazil. Simple statistical analyses were performed to evaluate quantitative data from
the “Floor Line” (Linha de chão) dynamic, and qualitative analysis was conducted on
individual evaluations collected via Google Forms®, supported by webQDA® software.
Ethical principles were observed.
Results
The "Floor Line" dynamic demonstrated a difference between pre- and post-course results,
with an increase in the number of correct answers to the statements presented during the
activity. Before the course, perceptions of palliative care were predominantly associated with
end-of-life care, with limited knowledge of legislation and related concepts such as
dysthanasia and orthothanasia. However, at both time points, professionals agreed that
primary health care should provide palliative care and that the home is an important
care setting.
Conclusion
The results indicate that health professionals need to improve their understanding of
palliative care, although they recognize its importance within primary health care. Challenges
must be addressed to ensure the comprehensive integration of palliative care throughout the
health care network, and professional training may offer an effective response. The course
proved an important educational tool for equipping health professionals and promoting
palliative care within the network, including primary health care.
Keywords
Primary Health Care; Palliative Care; Continuing Education; Public Health.
Juliana Zidan1
orcid.org/0000-0003-2235-1955
Audrei Castro Telles2
orcid.org/0000-0002-1191-5850
Bruna Sameneses dos Reis3
orcid.org/0009-0002-5093-7478
Adélia Teresa dos Santos Narciso Kiesse4
orcid.org/0009-0004-8766-8886
Eunice Sá5
orcid.org/0000-0001-5963-6087
Marcelle Miranda da Silva6
orcid.org/0000-0003-4872-7252
1 Bachelor of Nursing. Universidade Federal do Rio de
Janeiro, Rio de Janeiro, RJ, Brasil.
2 Master in Nursing. Universidade Federal do Rio de
Janeiro, Rio de Janeiro, RJ; Instituto Nacional de
Câncer José Alencar Gomes da Silva, Rio de Janeiro,
RJ, Brasil
3 Bachelor of Nursing, Oncology Specialist. Instituto
Nacional de Câncer, Rio de Janeiro, RJ, Brasil.
4 Bachelor of Nursing, Oncology Specialist. Instituto
Angolano de Controlo do Câncer, Maianga, Luanda,
Angola.
5 PhD in Nursing. Centro de Investigação, Inovação e
Desenvolvimento em Enfermagem de Lisboa
(CIDNUR), Escola Superior de Enfermagem de
Lisboa, Lisboa, Portugal.
6 PhD in Nursing. Universidade Federal do Rio de
Janeiro, Rio de Janeiro, RJ, Brasil; Centro de
Investigação, Inovação e Desenvolvimento em
Enfermagem de Lisboa (CIDNUR), Lisboa, Portugal.
Corresponding author
Marcelle Miranda da Silva
E-mail: marcellemsufrj@gmail.com
Received: 16.01.2025
Accepted: 11.04.2025
Editor:
Pedro Lucas
Zidan, J.
Qualitative Original Article
Introduction
The Unified Health System (Sistema Único de Saúde – SUS)
is a right guaranteed to all Brazilian citizens by the 1988
Federal Constitution, encompassing all health actions and
services provided by public and private institutions
throughout the country. Given SUS’s broad and complex
structure—similar to other international health systems—
the main entry point for accessing services is primary health
care, which includes a set of actions aimed at promoting
health, protecting against diseases, and preventing health
problems. Its core approach is to provide comprehensive
and holistic care throughout the life course, including
managing chronic conditions and end-of-life care1.
Regarding the management of chronic conditions that cause
suffering and may lead to death, palliative care is prescribed
and can be delivered across all levels of the Health Care
Network (Rede de Atenção à Saúde – RAS), including
primary health care2.
Investment in palliative care warrants significant attention
within health policy, given the high prevalence of
noncommunicable diseases (NCDs), such as cancer,
cardiovascular diseases, pulmonary diseases, and
neurodegenerative diseases. Each year, an estimated 17
million people under the age of 70 die from NCDs, with
86% of these deaths occurring in low- and middle-income
countries2. However, only 12% of global palliative care
needs are met, with services largely concentrated in
high-income countries3.
Thus, the participation of primary health care teams can
expand equity in access to palliative care and contribute to
promoting quality of life for patients and their families, as it
strengthens the relationship between primary care and
specialized palliative care resources available at other levels
of the RAS4,5. This integrated network of palliative care is
based on the principle of differentiating professional
qualifications across generalist, intermediate, and specialized
levels of care5, ensuring holistic care for individuals of all
ages, especially those nearing the end of life6.
With educational objectives focused on generalist palliative
care, family physicians, family nurses, and other health
professionals working in primary health care can assume
responsibilities in delivering these services, given that their
practice settings are often marked by the presence of older
individuals, people living with chronic conditions, and
patients at risk of death.
In this context, generalist palliative care delivered by primary
health care professionals can help improve the quality of life
for individuals requiring continued and long-term care by
identifying uncontrolled physical and psychological
symptoms, as well as social suffering5. To that end, primary
health care offers several strategies, including home-based
care, which can facilitate the implementation of palliative
care and, when articulated within the network, ensure
support for complex cases requiring specialized palliative
care and more advanced technological resources, such as
hospital admissions for pain control or management of
refractory symptoms.
However, primary health care in Brazil and other developing
countries has had limited involvement in delivering
palliative care despite playing a key role within the RAS and
being essential to integrated, person-centered care. This is
mainly due to the lack of knowledge about generalist
palliative care among health professionals, low health
literacy among the population regarding this subject, and the
fragility of the Health Care Network stemming from weak
integration with specialized palliative care services capable
of providing support during crisis management5,7.
Considering that avoidable suffering from treatable
symptoms persists because of the lack of knowledge about
palliative care, there is a pressing need for continuing
education and appropriate training for all health care
providers, whether in hospitals or community settings,
including workers from non-governmental organizations
and family caregivers8.
Moreover, integrating primary palliative care into the overall
provision of palliative care requires planning and
implementing educational initiatives for the general
population to raise awareness about the importance of
palliative care and its positive impact on quality of life. This
process begins with educating health professionals, who
must serve as agents of change, given their social
responsibility to translate knowledge into practice.
Therefore, palliative care must be incorporated into the
education of health professionals, especially through
Continuing Professional Development (CPD), which seeks
to enhance practices in primary health care by linking
management, education, service delivery, and
community engagement 9.
Once trained in generalist palliative care, primary health care
teams—particularly family physicians and family nurses—
can identify patients with palliative care needs and deliver
palliative care interventions to address less complex needs.
These actions include symptom management, empathetic
communication, care planning, education, and support, to
ensure the continuity and quality of care5.
In addition to addressing patients’ physical needs, health
professionals working in primary health care can also
manage the delivery of bad news, discuss death, handle
emotional responses, and explain complex end-of-life care
options10. Through CPD, these professionals can acquire
the knowledge and tools needed to guide patients’
therapeutic trajectories within the RAS, making appropriate
referrals to specialized palliative care teams based either in
hospitals or in community settings.
Thus, to highlight the importance of CPD, this study aimed
to assess health professionals’ perception of palliative care
in primary health care before and after a training course on
the basic principles of this field.
Pensar Enfermagem / v.29 n.Sup / Jan-Dec 202
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DOI: 10.71861/pensarenf.v29iSup.412 / e00412
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Methods
An uncontrolled quasi-experimental study was conducted
using a pre- and post-intervention evaluation design with a
single group of participants, following the Strengthening
the Reporting of Observational Studies in Epidemiology
(STROBE) guidelines in an adapted format. This design
was selected because it allowed the analysis of changes
within a single group, without a control group, focusing on
the immediate outcomes of the intervention.
The training course interventions were implemented in a
classroom of the Teaching and Research Coordination
Department of the National Cancer Institute (Instituto
Nacional de Câncer – INCA), in downtown Rio de Janeiro,
Brazil. The choice of this venue was justified because
INCA was one of the partner institutions in the doctoral
research project originating from the Anna Nery School of
Nursing, which employed action research methodology.
This study represented one of the learning activities
developed within the context of the Duque de Caxias
Municipal Health Department, in the state of Rio de
Janeiro, serving a population estimated at 866,347
inhabitants in 2024 and with a demographic density of
1,729.36 inhabitants per square kilometer in 2022.
Participant selection was carried out by convenience
sampling, including health professionals who met the
following criteria: (1) members of the multidisciplinary
team holding at minimum a bachelor’s degree; (2) formal
employment contracts; (3) availability to participate in
activities during the study period; and (4) a minimum of six
months of service in primary health care in the municipality
of Duque de Caxias, specifically within the Family Health
Support Center (Núcleo de Apoio à Saúde da Família – NASF),
the Home Care Service (Serviço de Atenção Domiciliar – SAD),
the Primary Care Department (Departamento de Atenção
Primária – DAP), or the Family Health Strategy (Estratégia
Saúde da Família – ESF). No exclusion criteria were
established. Professionals who were on any type of leave or
vacation during the training activity were not eligible to
participate in the study.
All study participants provided written informed consent in
accordance with ethical principles and guidelines for
research involving human subjects.
Two training cohorts were formed, each cohort completing
the course over two weekdays. The first cohort, composed
of eight health professionals, attended the course on July
25 and 27, 2023. The second cohort, composed of 15 health
professionals, attended on August 1 and 3, 2023.
The educational approach was in-person, combining
lectures, interactive discussions, and practical activities,
including the “Floor Line” dynamic to explore participants’
initial and final perceptions. For this dynamic, a line was
drawn on the floor, with one side representing “true” and
the other “false.” The course facilitator presented ten
statements about the philosophy and principles of palliative
care (Table 1), and participants were asked to think quickly
and respond according to their prior knowledge (pre-test)
or knowledge acquired (post-test). Those who did not
know the answer stood directly on the line, indicating
abstention.
The correct answers to the statements were discussed
immediately after the participants positioned themselves,
serving as a pedagogical tool to further explore specific
content during the course, whether the responses were
correct or incorrect.
Through observation and field notes, the entire dynamic
was documented with the assistance of two fellows from
the INCA Fellowship Program and an undergraduate
nursing student from the Federal University of Rio de
Janeiro, who received a scientific initiation scholarship. At
the end of the activity, the results were presented to the
cohort.
After the end of the course, the “Floor Line” dynamic was
repeated using the same set of questions from the initial
evaluation, and responses were recorded in the
same manner.
In addition, most participants completed a
self-administered final course evaluation form, which
included open-ended questions allowing them to identify
the most important learning points developed throughout
the course and to describe how the training contributed to
their professional development in generalist palliative care.
To analyze participants’ responses, we used the WebQDA®
software to create a word cloud highlighting the most
frequently mentioned terms.
Several strategies were employed to ensure the reliability of
the results: the combination of two distinct data collection
techniques; the use of software to systematically analyze
one set of qualitative responses; support from research
assistants throughout the intervention; and internal
validation through independent reviews conducted by two
experienced researchers to guarantee consistency in data
interpretation.
Course dynamic
The Training Course in Palliative Care for Higher Education
Health Professionals working in primary health care in the
municipality of Duque de Caxias was developed with lesson
plans organized in a structured and interconnected manner
to address the topic “Palliative Care,” using various active
learning methodologies. The course was divided and
organized over two days to make the training more dynamic
and engaging (Figures 1 and 2).
The course began with the previously described “Floor
Line” dynamic. Immediately afterward, a collaborative panel
activity was conducted. In this activity, the participants were
divided into four groups, each assigned to answer a specific
question: What do you understand by palliative care?
(Group 1); What do you understand by generalist and
specialized palliative care? (Group 2); In which settings can
Zidan, J.
Qualitative Original Article
palliative care be provided? (Group 3); and Which health
care team members can deliver palliative care? (Group 4).
The groups’ responses were posted on a panel and discussed
collectively.
Table 1: Sentences used in the “Floor Line” dynamic to assess health professionals’ perception of palliative care.
Following this activity, an interactive lecture was delivered
on palliative care’s concept, philosophy, and historical
background. In addition to the physical panel, an interactive
online board was created using the Padlet® platform,
allowing participants to further develop the topics.
All lectures and activities on the first day of the training
course were facilitated by the doctoral student, a nurse at
the National Cancer Institute (Instituto Nacional de Câncer –
INCA), who was responsible for the action research.
She also addressed the history of palliative care, the role of
the multidisciplinary team, the different care settings, and
the distinction between generalist and specialized palliative
care teams, frequently returning to the physical or online
board to reinforce the material as needed.
Building on the topics covered in the course, a
semi-structured panel was set up featuring the terms
“dysthanasia,” “euthanasia,” “orthothanasia,” and
“mistanasia.” The participants received cards with
prewritten definitions of these concepts and were asked, in
groups, to match each definition to the appropriate term on
the panel. In addition, the short film The Lady and Death was
shown to complement the interactive lecture on these
concepts and contextualize the integration between
generalist and specialized palliative care throughout the
course of serious illness.
With the screening of the documentary The Courageous End
of Ana Beatriz Cerisara, participants were introduced to
issues related to advance directives and shared
decision-making in palliative care. Based on this, the course
facilitator led a discussion on autonomy and
decision-making, grounded in the health care professionals’
code of ethics as it relates to palliative care.
The Brainstorming technique was used throughout the
activities, supported by the Mentimeter® app, with the
question: “What is the profile of the patients you serve?”
This exercise aimed to stimulate reflection on the
characteristics of individuals with palliative care needs and
the communication challenges involved in health-
illness situations.
This activity fostered a broader class discussion about the
need for palliative care within the RAS, illustrating key
ordinances, resolutions, and existing Brazilian legislation.
In addition, the facilitator addressed models of integrated
care and home-based care, the delivery of palliative care,
and the referral process and collaborative work with
specialized palliative care teams. Using Padlet® again and
applying the SWOT matrix, participants were asked how
palliative care could be incorporated into primary health
care, considering the strengths, opportunities, weaknesses,
and threats involved in making this happen.
Next, using the “Placard Response” dynamic, placards with
expressions symbolizing “yes” or “agree” and “no” or
“disagree” were distributed to participants to answer the
following questions: 1) Have you ever attended a class or
taken a course on health communication?; 2) Do you
encounter difficulties maintaining communication across
different levels of the RAS?; 3) Have you faced challenges
in maintaining effective communication in health care?; 4)
FLOOR LINE DYNAMIC
TRUE SENTENCES
have easy access to patients and families, are close to their homes, and are sensitive to
FALSE SENTENCES
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DOI: 10.71861/pensarenf.v29iSup.412 / e00412
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Have you faced challenges maintaining effective
communication in health care?
Following this, the video The Communication Processes was
shown, accompanied by an interactive lecture on specific
aspects of communication in health-illness situations, with
an emphasis on verbal and nonverbal communication when
conveying difficult news. Additionally, the session
addressed communication goals in critical situations,
progressive disclosure of difficult news, and the importance
of planning internal communication strategies within the
health unit team and among the various levels of the RAS.
Before another lecture on assessment scales, another
“Placard Response” dynamic was carried out, addressing
participants’ knowledge and use of assessment scales and
prognostic tools in palliative care, such as the Edmonton
Symptom Assessment Scale, the Palliative Performance
Scale, the Karnofsky Performance Status, the Eastern
Cooperative Oncology Group Performance Status (ECOG
PS), the Palliative Prognostic Scale (PaP), the Palliative
Prognostic Index (PPI), the Bristol Stool Scale, and the
Visual Analog Scale for pain measurement. Participants
who indicated familiarity were asked whether they applied
the respective scale in their professional practice.
At the end of the first day of the course, the “Floor Line”
dynamic was repeated as a formative final evaluation, using
the same questions from the initial assessment. The results
were recorded and analyzed in the present study.
On the second day of the course, the facilitator reviewed
the assessment scales before introducing additional topics
related to palliative care. The subjects covered on the
second day were presented by a physician from the INCA,
residents from the Oncology Residency Programs, and
fellows from the Palliative Care Fellowship Program in
Psychology, Physical Therapy, Nutrition, Medicine,
Nursing, and Social Work.
Regarding the analysis, for the quantitative data from the
“Floor Line” dynamic, we applied simple descriptive
statistics (absolute and relative numbers). For the
qualitative data from the overall course evaluation,
we conducted content analysis with the support of
WebQDA® software.
Ethical principles for research involving human subjects
were respected in accordance with Brazilian regulations,
following Resolution No. 466/2012 of the National Health
Council (Conselho Nacional de Saúde – CNS) and
Operational Standard CNS No. 001/2013. The research
project was approved by the ethics committees of the
proposing institution (as part of the doctoral research in
nursing) and the partner institutions, with final approval
granted on June 5, 2022.
Figure 1: Dynamic of the First Day of the Training Course
in Palliative Care for Higher Education Health
Professionals Working in Primary Health Care.
Figure 2: Dynamic of the Second Day of the Training
Course in Palliative Care for Higher Education Health
Professionals Working in Primary Health Care.
Results
Among the 23 participants, there was a wide variation in
age groups: seven (30,5%) were between 31 and 40 years
old, eight (34,7%) between 41 and 50 years old, five (21,7%)
between 51 and 60 years old, two (8,7%) between 61 and
70 years old, and one (4,4%) was between 20 and 30
years old.
Regarding professional categories, there were seven nurses,
two physical therapists, five social workers, one speech
therapist, two physicians, two dentists, two psychologists,
and two nutritionists. Six (26,1%) participants worked in
the NASF, seven (30,4%) in the ESF, six (26,1%) in the
SAD, and four (17,4%) in the DAP. Nine (39,1%)
participants reported between 6 and 10 years of
professional experience, eight (34,7%) between 6 months
and 5 years, and six (26,2%) between 11 and 25 years.
In terms of educational background, five (21,7%)
participants held a bachelor’s degree, 16 (69,6%) had
Zidan, J.
Qualitative Original Article
earned a graduate certificate, and two (8,7%) had earned a
master’s or doctoral degree.
The results of the “Floor Line” dynamic showed a notable
progression in the professionals’ knowledge before and
after the course, as can be seen in Table 2.
Table 2: Results of the “Floor Line” Dynamic
* One additional participant was included after arriving late.
In statement 2, which addressed specific legislation on
palliative care, the difference indicated that there was
initially a lack of awareness or clarity regarding the existence
of such legislation. After the course, 100% of the
participants reported awareness of the legal framework.
In statement 3, related to orthothanasia, the difference
between pre- and post-course results suggested that
participants gained confidence distinguishing ethical and
legal practices. In statement 7, regarding palliative care as a
multidisciplinary approach, the increased accuracy reflected
a better understanding that palliative care is not limited to
end-of-life situations but encompasses a holistic and
multidisciplinary approach that also prepares families for
the grieving process. Statement 8 revealed that none of the
participants had prior knowledge of the concept of
dysthanasia.
On the other hand, the high performance observed both
before and after the course on the remaining statements
indicated an important pre-existing understanding of the
role of primary health care and its ethical foundations in
palliative care.
Thus, these results suggest that the training had a significant
impact on participants’ understanding of legislation and
types of death, whereas basic concepts of palliative care
were already relatively familiar to the group.
In addition to the records from the “Floor Line” dynamic,
19 participants voluntarily completed the individual
evaluations via Google Forms®, providing the following
perceptions:
“It was a very good experience, learning and acquiring
knowledge I did not have before. It would be great to have
courses like this more often. It would be great if more
people could learn about and know how to handle palliative
care.” (P10)
“The course was surprisingly positive. It provided an
opportunity to discuss many aspects of health care that can
treat and bring comfort during a patient’s end-of-life
process in a light and approachable manner.” (P2).
Regarding the most important lessons learned, participants
shared the following experiences:
“I learned a lot about palliative care, what it is and how it is
delivered, and the types of support and the key issues for
patients and families who require specialized care. I learned
a lot about understanding the patient’s needs and how
essential communication is. I learned about building a
network among primary, specialized, and tertiary care to
“FLOOR LINE” DYNAMIC
Statements
PRE-COURSE RESULTS (n = 22)
POST-COURSE RESULTS (n=23*)
Correct
answers
Incorr
ect
answe
rs
Abstention
% of
correct
answers
Correct
answers
Incorr
ect
answe
rs
Abstention
% of correct
answers
1
(true)
22
0
0
100%
22
1
0
95,65%
2
(true)
10
3
9
45,45%
23
0
0
100%
3
(true)
10
0
12
45,45%
23
0
0
100%
4
(true)
22
0
0
100%
23
0
0
100%
5
(true)
22
0
0
100%
23
0
0
100%
6
(true)
21
0
1
95,45%
23
0
0
100%
7
(false)
7
14
1
31,80%
14
9
0
60,87%
8
(false)
0
5
17
0%
15
8
0
65,21%
9
(false)
20
2
0
90,90%
23
0
0
100%
10
(false)
22
0
0
100%
22
0
1
95,65%
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improve the overall coordination of services. This
connection and integration are extremely important.” (P5)
“At times, it was about demystifying concepts; at others,
about learning new concepts regarding medications used in
the treatment of patients with serious oncological diseases
[...]. Reinforcing the importance of multidisciplinary,
interdisciplinary, and humanized care, in which all team
members are equally involved in the patient’s history and
disease progression. The discussion about the existence of
federal and state laws on palliative care, and the need to
build policies to ensure the law is enforced, was also very
valuable.” (P8)
“I learned about the role of Primary Health Care in
palliative care and that, if proper matrix support is
provided, much can be accomplished at this level of the
health care network to ensure higher-quality care.” (P12)
Regarding how the course contributed to their professional
practice, participants responded:
“Using continuing education as a tool, encouraging services
to adopt the practices discussed during the course,
considering the various areas of knowledge involved, and
working with management to raise awareness about the
topic, identify allies, and promote and/or expand the
collaboration between Primary Health Care in Duque de
Caxias and Tertiary Care at the National Cancer Institute.”
(P16)
“In every way: in welcoming patients, in active listening, in
therapeutic planning, in supporting patients and their
families, in understanding all areas involved, and in
developing better intervention strategies to provide
comfort to patients at their most difficult moments.” (P1)
“This course helped me a lot, and I will be able to perform
better in my work setting since we have palliative care
patients. I will be more attentive to all issues involving the
patient and their family. I will also be able to share this
knowledge with my colleagues.” (P4)
Figure 3 shows the 50 most frequently used words by
participants in this general evaluation of the course.
Figure 3: Word cloud of the 50 most frequent words from
participants' overall evaluation of the palliative care training
course.
Discussion
The results of the “Floor Line” dynamic, before and after
the training course, demonstrated an increase in the
number of correct responses following the interactive
lectures and educational activities on the topic, particularly
concerning the concept of palliative care, types of death,
the Brazilian legal framework, and international guidelines.
A strong final performance regarding knowledge of the
legal framework for palliative care is critical for
implementing and supporting clinical practices. Similarly,
understanding concepts such as orthothanasia and
dysthanasia enhances perceptions of dignified death with
alleviated suffering and influences ethical and professional
conduct.
However, mastery of the core concept of palliative care did
not reach 100%, suggesting that foundational knowledge in
this area still requires reinforcement. This finding is
consistent with a study involving 181 Brazilian nurses
working in primary health care, which revealed that
knowledge of palliative care remains limited11. Insufficient
understanding of the philosophy and principles of palliative
care undermines the ability to identify patients requiring
such services and, consequently, to make appropriate
referrals to specialized teams, ultimately compromising
comprehensive care11.
These statements that showed strong performance both
before and after the course raise important points,
particularly regarding the fact that professionals recognized
their proximity to families and the community as a key
strength in supporting palliative care. All participants
acknowledged the potential of primary health care within
the RAS to promote generalist palliative care, as evidenced
by the unanimous correct responses to statement 4, even
before the course. However, despite this recognition,
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Qualitative Original Article
managerial issues identified by participants at both
evaluation points indicate that primary health care faces
challenges in effectively and comprehensively serving all
populations, such as resource limitations and insufficient
professional knowledge in certain care areas.
These difficulties are compounded by the growing need to
integrate palliative care into the training of health
professionals, given the aging population and the rising
demand for holistic care that addresses physical, emotional,
and spiritual dimensions12.
Nevertheless, the prior recognition that primary health care
professionals can make a difference in palliative care—
because of their easy access to patients, proximity to
homes, and sensitivity to the community context—is
crucial for strengthening actions aimed at improving the
quality of life for individuals with chronic or end-of-life
conditions. This recognition also contributes to improving
quality indicators for palliative care, such as increasing the
time patients remain at home and reducing emergency
department visits and inappropriate hospitalizations13.
This is because recognizing palliative needs and addressing
fewer complex demands through the efforts of primary
health care professionals can expand access to palliative
care. By focusing on relieving pain and other distressing
symptoms and promoting effective communication, these
actions improve patients’ and their families’ quality of life
and even contribute to supporting home death14.
Thus, integrating palliative care into home-based services
aligns with meeting many individuals’ wishes and
preferences, as studies show that home death is the
preferred option for many patients at the end of life,
especially among older adults15. Moreover, home care
strengthens primary health care and optimizes health
system resources. Home visits ensure adequate care within
the family setting, with continuous support from family
physicians and nurses16.
However, strategies and resources for professional training
are essential to overcome the identified barriers and to
foster the effective integration of palliative care into
primary health care. Continuing education is one of the
effective tools to promote compassionate and holistic care,
ensuring that patients and their families receive the
necessary support during challenging moments in their
lives and are able to maintain their wish to remain at home.
Health professionals must possess broad knowledge and
the skills necessary to adequately meet patients’ needs and
be equipped to work as part of a team in close coordination
with specialized palliative care services whenever needed.
Moreover, continuing education strengthens professionals’
abilities to engage in discussions about prognosis,
treatment options, and end-of-life preferences while
fostering the development of sensitive and effective
communication skills delivered in a compassionate and
humanized manner17.
Furthermore, the results from statements 3 and 8, which
explore concepts related to types of death, reveal that even
though these concepts are not recent, they are still poorly
disseminated and often misunderstood. Studies indicate
this deficiency stems from gaps during undergraduate
education for health professionals, as palliative care is often
not included in curricula, particularly topics involving
bioethics18. This reality underscores the importance of
integrating palliative care education into ongoing
professional development initiatives, using continuing
education as an essential tool. It also emphasizes the need
to engage in community health education, to explain the
differences between types of death, clarify the ethical and
practical contexts in which each applies19, and foster
discussions about the legal and ethical implications, helping
health professionals to facilitate informed and ethically
sound decision-making processes in accordance with the
country’s legal and ethical standards20.
Based on this understanding, it is important to note that the
lack of knowledge about palliative care legislation,
combined with the need for greater awareness and
education among both professionals and the general public,
represents a major obstacle to the effective implementation
of palliative care. Awareness of citizens’ rights and
responsibilities is essential to advocate for public policies
and foster community engagement, ensuring that palliative
care services are understood, valued, and appropriately
integrated into the health system.
The implementation of the training course can contribute
to strengthening the palliative care network within the SUS,
ensuring comprehensiveness, accessibility, and patient- and
family-centered care. An integrated and collaborative
approach among RAS services, involving greater primary
health care participation in generalist palliative care,
improves the quality of care delivery and optimizes
resource utilization.
Ongoing professional development in health care, focusing
on continuous training and qualification, is a central aspect
of the National Policy on Continuing Education, which
aims to develop strategies for the continuity and
comprehensiveness of health services21. Continuing
education should be understood as a ongoing process
tailored to the needs and guidelines of the health system,
particularly within the contexts where practice occurs22.
Aligned with global recommendations for professional
training in palliative care2 and grounded in scientific
evidence, the course commits to transferring knowledge
into practice and improving health indicators. It represents
a strategic approach that seeks cumulative results in
professionals’ acquisition of knowledge and experience, as
well as in promoting public health education on palliative
care. It emphasizes adapting and integrating palliative care
into public health according to each community’s needs,
available resources, and cultural context.
The course experience was consistent with the findings of
a systematic review on professional development in
palliative care for primary health care providers, which
highlighted the importance of combining different teaching
Pensar Enfermagem / v.29 n.Sup / Jan-Dec 202
5
DOI: 10.71861/pensarenf.v29iSup.412 / e00412
Qualitative Original Article
methods and fostering interprofessional collaboration to
enhance attitudes, confidence, knowledge, and skills23,
as evidenced by the participants’ feedback in the individual
course evaluations.
Conclusion
The results confirmed that health professionals need to
improve their understanding of palliative care, although
they recognize the potential and importance of this field
within primary health care. Challenges must be overcome
to ensure the comprehensive integration of palliative care
throughout the continuum of care. In addition,
professional training can serve as an effective strategy, as
the course successfully addressed critical gaps, such as
knowledge of legislation, bioethics concepts, and
multidisciplinary approaches. At the same time, it
reinforces existing competencies and promotes a deeper
conceptual and practical understanding of palliative care.
The findings reinforce the role of continuing education in
health care as an essential pillar for enhancing the quality of
palliative care delivery. The training course demonstrated
its value as an advanced strategy to expand professionals’
knowledge, enabling them to promote high-quality
palliative care within an integrated network. It is
recommended that palliative care training programs be
systematically incorporated into ongoing professional
education and that institutional policies be strengthened to
include palliative care instruction beginning at the
undergraduate level.
Future research should explore the long-term impact of
such training programs, evaluating changes in clinical
practice, patient care planning, and the overall level of
health literacy within the population.
Study limitations
This study has some limitations. The evaluation dynamic
was conducted on the same day, which does not guarantee
long-term retention of knowledge; much of what was
learned may have been forgotten, and there was also
potential for fatigue at the end of the day and test bias due
to recall of previous answers. Additionally, the absence of
one participant during the initial stage of the “Floor Line”
dynamic limited the completeness of the pre- and post-
course comparison, as no exclusion or individualization of
responses had been planned to address potential absences.
Nevertheless, conducting the pre- and post-evaluation with
the same group of participants was an important strategy to
strengthen internal validity. Other variables were also
controlled, such as the voluntary nature of participation and
the absence of financial incentives, ensuring the
participants’ genuine interest in the training. Furthermore,
all participants held a higher education degree and worked
in the same professional environment.
Authorship and Contributions
Zidan J: Conception and design of the study, data collection,
data analysis and interpretation, statistical analysis and
writing of the manuscript.
Telles AC: Study conception and design, data analysis and
interpretation, statistical analysis and critical revision of the
manuscript.
Reis BS: Data collection, data analysis and interpretation,
statistical analysis and critical revision of the manuscript.
Kiesse AT: Data collection, data analysis and interpretation,
statistical analysis and critical revision of the manuscript.
Sá E: Conception and design of the study, analysis and
interpretation of the data and critical revision of the
manuscript.
Silva MM: Conception and design of the study, data
collection, data analysis and interpretation, obtaining
funding and writing the manuscript.
Conflicts of interest and Funding
No conflict of interest.
Acknowledgements
To FAPERJ and CNPq for their financial support
throughout the study.
Sources of support / Funding
The first author received a Scientific Initiation grant from
the Rio de Janeiro State Research Foundation
(FAPERJ/RJ). The second author received a scholarship for
a sandwich doctorate abroad from the National Council for
Scientific and Technological Development (CNPq), Brazil.
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